Question

Fee-for service or managed care:which has higher copays and deductibles?

Answer 1

Explanation:

I’ll describe this in simplest terms. Things can be considerably more complex that this, and many reimbursement model variants exist in between these two “extremes”

Fee for Service : the provider (e.g. doctor or hospital) bills the insurer. The insurer adjudicates the claim, and reimburses the provider at rates that have been agreed upon by the two, less any portions for which the patient is held responsible per the terms if their policy.

(Large provider organizations may negotiate their own reimbursement schedules with insurers. Smaller ones mostly just make “take it or leave it” decisions on whether or not they want to accept the insurer’s members as patients, based on whether the insurer’s reimbursement rates appear acceptable to them in light of how badly they need access to the insurer’s supply of patients.)

In this model, all risk is carried by the insurer and its members. The insurer’s risk is that its members will require care for which it must pay out as just described. The members’ risk consists of how much they might have to pay in the form of deductibles, co-payments, and coinsurance if they require care. The providers mostly avoid risk because even if they end up treating a particularly expensive mix of patients, their revenue will go up accordingly.

Capitation : the provider is compensated primarily by a flat amount - the ‘capitation amount’ - that the insurer pays to them, per member/per month. Typically there will also be co-pays that are the responsibility of the member/patient. Then it is up to the provider to do its best to manage how it treats its cap patient population so that its costs of caring for them do not exceed the corresponding cap income.

In this model, considerable risk has been shifted to the provider. (Not all of it. There typically are provisions in the insurer-provider agreement that shift risk back to the insurer in circumstances of high patient utilization beyond the provider’s control. As previously noted, there can be many variants. And of course the member/patients still bear some risk with the copays etc.). This model creates incentive for the provider to think and act like they are “part provider, part insurer”. It is an “in between” model that stops short of the providers and insurer becoming one-and-the-same business (like Kaiser is, for example).

Sorry for the Subheadings letters

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